TREATMENT OF ANTERIOR FEMOROACETABULAR IMPINGEMENT
WITH COMBINED HIP ARTHROSCOPY AND
LIMITED ANTERIOR DECOMPRESSION
John C. Clohisy, M.D. and J. Thomas McClure, M.D.
ABSTRACT
Anterior femoroacetabular impingement results
from abnormal abutment of the anterolateral femo-
ral head-neck junction with the anterior acetabu-
lar-labral complex resulting in pain and progres-
sive hip dysfunction. This under-recognized
problem could be the manifestation of acetabular
or proximal femoral deformity, and when left un-
treated leads to the development of osteoarthritis
of the hip. Conser vative treatment is usually un-
successful and the optimal surgical treatment for
these disorders needs to be determined. We
present our technique for treating femoral (cam)
impingement which combines hip arthroscopy and
a limited open anterior head-neck osteoplasty as
a less invasive and more conser vative surgical
approach, which still adequately addresses the
anatomy and pathophysiology of this disease.
INTRODUCTION
Impingement of the femoral neck on the anterior rim
of the acetabulum (anterior femoroacetabular impinge-
ment) has been described in conjunction with malunited
femoral neck fractures,3 acetabular dysplasia,12 acetabu-
lar retroversion,32,33 and as a complication of peria-
cetabular osteotomy.25 Increasingly, it is being recog-
nized as a cause of significant hip pain and disability
and is strongly implicated as a cause of secondary os-
teoarthritis.5,6,23 In 1999, Ganz and colleagues reported
the development of a secondary impingement syndrome
as a complication of periacetabular osteotomy.25 The
femoral head-neck junction abutted the anterior rim of
the acetabulum leading to pain in five patients after re-
positioning of the dysplastic acetabulum. Most impor-
tantly, successful resolution of anterior impingement
Department of Orthopedic Surgery
Barnes-Jewish Hospital / Washington University School of
Medicine
St. Louis, Missouri
Correspondence:
John C. Clohisy, MD
660 South Euclid, Campus Box 8233
St. Louis, MO 63110
Telephone: 314-747-2566
FAX: 314-747-2599
jclohisy@msnotes.wustl.edu
164 The Iowa Orthopaedic Journal
symptoms was noted after surgical treatment of the
anterior impingement lesion.
Although anterior femoroacetabular impingement
was initially described as a complication of surgery and
noted to be secondary to several other deformities, it
has recently and appropriately been recognized as a
disease process unto itself and as a significant cause of
hip pain in younger patients.1,5,23,34,38 Femoroacetabular
abutment is classified as either pincer or cam impinge-
ment.5 Pincer-type impingement has been associated
with acetabular retroversion,32 protrusio acetabuli, and
coxa profunda33 due to the relative over-coverage by the
anterior rim producing a linear contact between the rim
and femoral neck.5 Cam impingement is the result of
decreased head-neck offset with a gradual aspherical
contour from the femoral head to the neck
anterolaterally with a relative retroversion of the femo-
ral head.10,34 This results in an increased radius of cur-
vature anteriorly with a triangular shaped extension of
bone and articular cartilage onto the femoral neck. This
osteochondral lesion impacts the acetabular rim with
flexion and internal rotation of the hip.34 The suspected
etiology of this lesion is abnormal physeal development
6,20,28
but it can also occur in slipped capital femoral epi-
physis (SCFE),15,30 Legg-Calve-Perthes disease, and
malunited femoral neck fractures.3
Interestingly, the histopathological and morphologi-
cal changes seen in the labrum and cartilage with both
cam and pincer impingements are similar to and con-
sistent with chronic degeneration without signs of acute
inflammation9 and an etiology of repetitive microtrauma.
Impingement of the femoral head-neck prominence onto
the acetabular rim initially leads to hypertrophy of the
anterior-superior labrum with intrasubstance degenera-
tion. Over time, delamination of the acetabular cartilage
of the superior acetabular rim-labral junction occurs, and
degenerative labral tears are produced anteriorly by
repetitive compression and sheer forces. As the femo-
ral head levers out of the acetabulum with flexion, a
distraction force occurs on the posterior capsular-labral
junction resulting in the development of a posterior
counter-lesion with small tears noted in the posterior
labrum. As severity of the disease progresses, the en-
tire labrum becomes degenerative with further delami-
nation of the acetabular articular cartilage and subse-
quent wear damage to the anterior portion of the
 Treatment of Anterior Femoroacetabular Impingement

Figure 1. Radiograph demonstrating severe arthrosis of the right

hip secondar y to untreated femoroacetabular impingement in a
thirty-eight year old patient. Note the aspherical femoral heads bi-
laterally.

femoral head. The end result of this process is the de-

velopment of global hip arthrosis (Figure 1).
Early surgical intervention has been proposed to
avert the pathologic sequence of events starting with
impingement and resulting in end-stage arthrosis. Spe- Figure 2a

cifically, Ganz and colleagues have recommended sur-

gical dislocation of the hip to treat this disorder.4 The
purpose of this report is to describe an alternative, less-
invasive surgical strategy for the treatment of early
femoroacetabular impingent that combines hip
arthroscopy and a limited osteoplasty of the anterior
head-neck junction.
Figure 2. Case ExampleA 21-year old collegiate wrestler with
symptomatic anterior femoroacetabular impingement. AP (a) and
frog-leg lateral (b) radiographs demonstrate an aspherical femoral
head with deficient head-neck offset anterolaterally. Eighteen-month
follow-up frog lateral.

CLINICAL AND RADIOGRAPHIC EVALUATION

OF ANTERIOR FEMOROACETABULAR
IMPINGEMENT
Histor y
Anterior femoroacetabular impingement usually pre-
sents in young athletic patients less than 50 years old
and involved in activities that require repetitive hip flex-
ion. These patients frequently complain of hip discom-
fort with sitting and hip flexion activities. The location
of the discomfort is predominantly in the groin (ante-
rior inguinal), but can be associated with buttock and
lower lumbar discomfort. Anterior femoroacetabular
impingement is consistently associated with anterior
labral pathology. Therefore, patients may complain of
mechanical symptoms (locking, catching, and giving
way) indicative of labral tears or articular cartilage
delamination lesions. Patients with more severe defor-
mity may also complain of restricted hip motion, spe-
cifically limited hip flexion and limited internal rotation
in flexion. When interviewing the patient, it is impor-
tant to elicit any history of previous hip disease or hip
surgery, especially SCFE. After characterization of the Figure 2b

patient history and symptoms, a careful physical exami-

nation is critical.

Volume 25 165
J. C. Clohisy and J. T. McClure
Figure 2c. MR arthrogram shows hypertrophic degenerative labral
tear and aspherical femoral head.
Physical Examination
On physical examination, the patients gait is either
normal or slight limp will be present occasionally. A
Trendelenburg test may be positive, especially if the
disease is more established. Abductor strength is rou-
tinely assessed and commonly reveals slight weakness.
Hip motion should be evaluated very carefully. A re-
striction of hip flexion and hip internal rotation is quite
common. Many of these patients have hip flexion lim-
ited to 90-100 degrees (normally 120-130 degrees). In-
ternal rotation in 90 degrees of flexion is quite restricted
and is usually between 0 and 10 degrees. This restricted
internal rotation in hip flexion is due to osseous impinge-
ment of the anterolateral femoral head-neck junction
with the acetabulum.27 The anterior impingement test
is almost universally positive and should reproduce the
symptom of groin pain.18 Posterior impingement of the
hip is assessed with the patient in a prone position. The
hip is extended and externally rotated to produce pos-
terior impingement of the head-neck junction with the
posteroinferior rim of the acetabulum. Posterior im-
pingement is more common as the disease progresses
and a posteroinferior traction osteophyte develops which
can produce clinical symptoms of posterior impinge-
ment in extension.
166 The Iowa Orthopaedic Journal
Radiographic Evaluation
Radiographic evaluation includes an AP pelvis, false-
profile view, frog lateral view, and cross-table lateral view
of the hip. The cartilage space of the hip is assessed
and any structural abnormalities about the hip are
noted. Specifically assess the acetabular version,19 lat-
eral femoral head coverage,14 anterior femoral head cov-
erage,40 inclination of the acetabular articular surface,39
and the contour and sphericity of the femoral head.2,7,22,24
Specific attention is directed to the head-neck region.
Fullness or a prominence of this region laterally on the
AP view is indicative of anterolateral disease (Figure
2a). The frog lateral and cross-table lateral radiographs
are used specifically to quantify the femoral head-neck
offset along the anterolateral aspect of the head-neck
junction (Figure 2b). 2,6,24 The head-neck offset is mea-
sured on the cross-table lateral radiograph using a
method described by Eijer et al.2 A line bisecting the
longitudinal axis of the femoral neck is drawn; however,
this is not necessarily through the center of the femo-
ral head. A parallel line tangent to the anterior femoral
neck and a second parallel line tangent to the anterior
femoral head are then drawn. The perpendicular dis-
tance between these two lines is the measured head-
neck offset, with a value less than nine millimeters be-
ing abnormal. The offset ratio is determined by the ratio
of the head-neck offset distance relative to the diam-
eter of the femoral head, with a value of less than 0.17
being abnormal.2 In patients with subtle radiographic
findings and questionable femoroacetabular impinge-
ment, a hip motion exam with fluoroscopy can deter-
mine the presence or absence of osseous impingement.
MRI arthrography can provide additional information
regarding the integrity of the acetabular labrum,
anatomy of the head-neck junction and the degree of
acetabular cartilage deterioration (Figure 2c).11,16,17,29
Surgical Techniques
The basic principle of surgical treatment of anterior
femoroacetabular impingement is to restore sphericity
to the femoral head, thereby relieving the impingement,
and to also address the pathologic changes in the la-
brum and articular cartilage. Treatment can be tailored
to the specific pattern of the disease. In cases of cam
anterior femoroacetabular impingement, the offending
lesion is consistently located in the anterolateral aspect
of the femoral head-neck junction.27 This has led to the
treatment approach we describe below which addresses
this disorder with a less-invasive surgical approach.
The patient is positioned supine on a standard frac-
ture table. We presently prefer general endotracheal
anesthesia with muscle relaxation to aid in distraction

Figure 2d Figure 2e
Figure 2g
At arthroscopy, the patient had an anterior labral tear (d), and early articular cartilage delamination (e). These lesions were treated with
arthroscopic debridement (f). Intraoperative fluoroscopic views demonstrating the aspherical femoral head (g) and restoration of head-neck
of fset (h) after anterolateral osteoplasty.
of the joint. The first stage of the operation is a hip
arthroscopy to inspect the severity of disease and to
address labral and articular cartilage lesions. We per-
form this with slight hip abduction (5) and slight inter-
nal rotation of the lower extremity (5). The hip is main-
tained in a neutral position of flexion and extension. The
joint is distracted 8-10 mm with fracture table traction.
We utilize the anterior, anterolateral and posterolateral
portals. These are established with fluoroscopic assis-
tance placing 5.0, 4.5 and 4.0 mm cannulated hip
ar throscopy cannulas (Dyonics, Smith&Nephew,
Andover, MA) in the respective portals. The joint is
systematically evaluated with both a 70-degree and 30-
degree angled arthroscope. The articular cartilage of
the femoral head, the acetabulum and the acetabular
labr um are inspected. In patients with anterior
femoroacetabular impingement complex, degenerative
tears of the anterior and anterolateral acetabular labrum
are common (Figure 2d). These labral lesions are fre-
quently associated with delamination of the adjacent
articular cartilage at the transition zone (Figure 2e). In
more severe cases, the labral and adjacent articular
cartilage disease can extend along the entire anterior
Treatment of Anterior Femoroacetabular Impingement
Figure 2f
Figure 2h
and lateral margin of the acetabulum. It is also com-
mon to find articular cartilage disease at the articular-
labral transition zone posteroinferiorly. In early stages,
these posterior changes are mild, and major unstable
flaps of articular cartilage are uncommon. Labral dis-
ease posteriorly is commonly less extensive and less
severe. After careful inspection of the joint, the unstable
labrum and articular cartilage disease are treated with
conservative debridement (Figure 2f). We employ the
combination of a ligament chisel (Vulcan EAS, Oratec
Interventions, Menlo Park, CA), full-radius shaver and
an aggressive arthroscopic shaver (Linvatech, Largo,
FL) to debride unstable flaps of acetabular labrum and
associated articular cartilage flaps. Care is taken to re-
sect only unstable regions of the labrum and articular
cartilage. Further delamination of the articular margin
is possible if aggressive resection is performed. After
the anterior labral and chondral debridement is per-
formed, we proceed with a conservative debridement
of the posteroinferior acetabular labrum and associated
articular cartilage if necessary. After arthroscopic de-
bridement is completed, the joint is irrigated, instru-
ments are removed, and traction is released.
Volume 25 167
J. C. Clohisy and J. T. McClure

After completion of the hip arthroscopy, the patient rotation. The goal of the osteoplasty is to remove all
remains in the same position and open debridement is prominent anterolateral osteochondral tissue that con-
performed or the patient is repositioned for a limited, tributes to an aspherical shape of the femoral head. If
open anterior decompression of the hip. Prior to inci- sphericity has not been achieved, additional resection
sion, fluoroscopy images are taken to insure excellent of the head-neck junction is performed. Bleeding from
visualization of the proximal femur, specifically the femo- the surface of the osteoplasty is controlled with bone
ral head-neck junction. This is best visualized with a wax. The joint is irrigated and the longitudinal and su-
cross-table lateral or a frog-leg lateral view (Figure 2g). perior transverse arms of the arthrotomy are closed
Internal rotation in the frog lateral position can better with absorbable sutures. The direct and reflected heads
define the anterolateral osteochondral prominence. An of the rectus tendon are repaired with nonabsorbable
8-10 cm incision is then made, starting just inferior to suture and the remainder of the wound is closed in stan-
the anterior superior iliac spine and incorporating the dard fashion.
previous anterior arthroscopy portal incision. Dissec-
tion is carried through the subcutaneous tissue later- Post-operative Care
ally to dissect directly onto the fascia of the tensor fas-
Postoperatively, patients are observed overnight in
cia lata muscle. The fascia is incised, and the muscle
the hospital. Physical therapy is instituted for toe-touch
belly is retracted laterally. The fascia is reflected medi-
weight bearing with crutches to minimize the risk of
ally. This medial sleeve of tissue contains the lateral
femoral neck stress fracture. A pillow is used under the
femoral cutaneous nerve which should be protected by
thigh to protect the rectus repair and active flexion is
placing the fascial incision lateral to the tensor-sarto-
avoided for six weeks. Abductor strengthening is insti-
rius interval. The interval between the tensor and sar-
tuted immediately and continued with a home exercise
torius is then developed. The rectus origin is identified,
program. Crutches are discontinued at six weeks and
and the direct and reflected heads are released. The
activities are resumed gradually as tolerated. Impact
rectus is reflected distally and the adipose tissue and
activities like running are not encouraged for at least
iliocapsularis muscle fibers are dissected off the ante-
six months. Aspirin 325mg is taken as thromboembolic
rior hip capsule. An I-shaped capsulotomy is then per-
prophylaxis and indomethacin 75mg sustained release
formed to provide adequate exposure of the anterolat-
is utilized for heterotophic ossification prophylaxis. Both
eral femoral head-neck junction. Most commonly, an
are taken for six weeks.
outgrowth of osteochondral tissue is observed along the
anterolateral head-neck junction. The offset from the
DISCUSSION
femoral head to the neck in this region is deficient. The
The contour of the femoral head and neck radio-
normal head-neck offset anteromedially serves as a ref-
graphically has been noted to be a predictor of anterior
erence point for resection of the abnormal osteochon-
femoroacetabular impingement.27 The oval-shaped head,
dral lesion. A half-inch curved osteotome is utilized to
as seen on the AP radiograph, has been described as a
perform an osteoplasty at the head-neck junction. The
pistol-grip deformity.37 This anterolateral prominence,
osteotome is directed distally and posteriorly to perform
however, is best recognized on lateral radiographs.2 The
a beveled resection to prevent delamination of the re-
pistol-grip deformity has, over the years, been corre-
tained femoral head articular cartilage. After the osteo-
lated with idiopathic osteoarthritis.7 Subclinical slipped
plasty is performed and the head-neck offset has been
capital femoral epiphysis has been suggested as a pos-
established anterolaterally, the accuracy of the surgical
sible cause of this deformity, and thus, of secondary
resection is confirmed with intra-operative fluoroscopy.
osteoarthritis.24,35,36,37 Other authors have disputed this
The frog-leg lateral or cross-table lateral views in neu-
suggestion and attribute the deformity to secondary
tral and varying degrees of internal rotation are very
remodeling of the proximal femur as a result of idio-
effective for visualizing the anterolateral head-neck junc-
pathic osteoarthritis itself.8,31 Goodman et al. noted that
tion (Figure 2h). The hip can also be examined at this
the post-slip morphology was present at a constant rate
time to assess impingement in hip flexion and combined
in multiple age groups, thus implying that the defor-
flexion and internal rotation. This is performed while
mity was primary and not secondary to remodeling from
palpating the anterior hip to test for residual impinge-
osteoarthritis.6 It was also suggested in the same study
ment. If the anterior acetabular rim is overgrown sec-
that the deformity might represent an anatomical vari-
ondary to labral calcification or osteophyte formation,
ant in the shape of the adult femur instead of a conse-
this is carefully debrided until adequate clearance is
quence of unrecognized childhood disease. Moreover,
achieved. Hip motion should improve at least 5-15 de-
it was hypothesized that this variant could result in con-
grees in flexion and at least 5-20 degrees in internal
tact between the femoral neck and acetabulum with flex-

168 The Iowa Orthopaedic Journal


ion and internal rotation, leading to the development of
osteoarthritis. The contention that the deformity is an
anatomic variant rather than the consequence of a sub-
clinical SCFE is further supported by an MRI study
showing that the orientation of the capital physeal scar
remains in normal position in these patients.34
Surgical treatment of femoroacetabular impingement
has been described by Ganz and colleagues,5 who de-
veloped an approach that involves dislocation of the hip
joint anteriorly with a trochanteric flip osteotomy.4 This
allows for access to the femoral head for debridement,
and open debridement of the labrum and acetabular rim,
and has been combined with femoral osteotomy, when
needed, to address the various causes of femoroacetab-
ular impingement.1,3,5,13,23,25,38 This surgical approach was
reported in 2001 by Ganz for the treatment of multiple
hip pathologies and included 164 patients with anterior
impingement.4 Average blood loss was 300ml with an
average of eight weeks until osteotomy healing, and four
to six additional weeks to regain abductor strength. The
overall incidence of heterotopic ossification was 37 per-
cent and there were two transient sciatic nerve palsies.
While there were no reported cases of avascular necro-
sis (AVN) in the initial description of the procedure,
laser Doppler flowmetry showed transient changes in
head perfusion during the procedure, which returned
to baseline after reduction of the joint.26 The disloca-
tion also requires the rupture or division of the liga-
mentum teres with loss of its proprioceptive nerve fi-
bers, the consequences of which are cur rently
unknown. In a midterm report of 19 patients with aver-
age follow-up of 4.7 years, Beck et al. noted that there
was significant improvement in the pain score and the
overall Merle dAubigne hip score. Five hips were con-
verted to total hip arthroplasty(THA), while the rest
were rated with good or excellent results. There were
no instances of AVN reported.1
Possible surgical treatment options for anterior
femoroacetabular impingement include hip dislocation
with trochanteric osteotomy, arthroscopy alone, or as
we recommend, hip arthroscopy with limited anterior
decompression. The inciting mechanical lesion in pri-
mary anterior femoroacetabular impingement is consis-
tently located along the anterolateral head-neck junc-
tion.27 In early and mid stages of the disease process,
intraarticular pathology is limited to labral degenera-
tion and tears associated with small articular cartilage
lesions and delamination around the acetabular rim.9
These lesions can be addressed appropriately with the
arthroscopic portion of the procedure. Advanced chon-
dral lesions have not responded well to open debride-
ment, with a high incidence of progression and subse-
quent conversion to THA.1,23 In their original reported
Treatment of Anterior Femoroacetabular Impingement
Figure 2i. Demonstrates maintained head-neck offset without pro-
gression of degenerative changes.
series of open debridements via hip dislocation, Ganz
and colleagues made an intraoperative decision to per-
form primary THA on patients with advanced chondral
lesions.4
While we admittedly have no experience with
arthroscopic debridement of the bony impingement
deformity, our experience with hip arthroscopy11 has
verified the efficacy of arthroscopy for labral pathology.
Our current opinion is that debridement of the femoral
head-neck junction arthroscopically has certain poten-
tial disadvantages including the potential for inadequate
exposure of the anterolateral head-neck junction, the
potential for bony debris to become entrapped in the
joint, and the possibility of inadequate osseous debri-
dement.
We have taken an intermediate approach to treating
this disease, which combines the advantages of hip
arthroscopy with an open osteoplasty of the femoral
head-neck junction. The arthroscopy addresses the
labral disease at the acetabular margin and any associ-
ated chondral damage. Additionally, posterior labral and
ar ticular cartilage disease is accessed and treated
arthroscopically. The open osteoplasty is performed via
a limited anterior approach through the Smith-Peterson
interval. This allows excellent exposure of the antero-
lateral femoral head-neck junction and the anterior and
lateral acetabular rims. This provides adequate expo-
sure for osteoplasty of these anatomic sites. The expo-
sure also allows visualization of the anteromedial head-
neck junction, which is an excellent reference point for
normal neck contour. This exposure combines the ad-
Volume 25 169
J. C. Clohisy and J. T. McClure
vantages of a less invasive surgery with a theoretical
lower complication rate. Importantly, we do not advo-
cate the use of this procedure for more advanced dis-
ease with posterior impingement lesions, or for hips that
have circumferential lesions of the femoral head. In
these cases, trochanteric osteotomy and surgical dislo-
cation as described by Ganz et al. provides superior
exposure to address more extensive disease patterns.4
This report presents our current surgical technique
for primary cam femoroacetabular impingement and the
disease pattern relevant to its development. In our ini-
tial cohor t of patients treated with this procedure
(Clohisy, unpublished data), we have been very satis-
fied with the rapid recovery and clinical results over
the short term (Figure 2i). While our early results with
this technique are promising, continued follow-up for
mid-term and long-term results is essential to verify the
efficacy of this technique.
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